Abstract
BackgroundStroke is the second most common cause of seizures in term neonates and is associated with abnormal long-term neurodevelopmental outcome in some cases.ObjectiveTo aid diagnosis earlier in the postnatal period, our aim was to describe the characteristic EEG patterns in term neonates with perinatal arterial ischaemic stroke (PAIS) seizures.DesignRetrospective observational study.PatientsNeonates >37 weeks born between 2003 and 2011 in two hospitals.MethodContinuous multichannel video-EEG was used to analyze the background patterns and characteristics of seizures. Each EEG was assessed for continuity, symmetry, characteristic features and sleep cycling; morphology of electrographic seizures was also examined. Each seizure was categorized as electrographic-only or electroclinical; the percentage of seizure events for each seizure type was also summarized.ResultsNine neonates with PAIS seizures and EEG monitoring were identified. While EEG continuity was present in all cases, the background pattern showed suppression over the infarcted side; this was quite marked (>50% amplitude reduction) when the lesion was large. Characteristic unilateral bursts of theta activity with sharp or spike waves intermixed were seen in all cases. Sleep cycling was generally present but was more disturbed over the infarcted side. Seizures demonstrated a characteristic pattern; focal sharp waves/spike-polyspikes were seen at frequency of 1–2 Hz and phase reversal over the central region was common. Electrographic-only seizure events were more frequent compared to electroclinical seizure events (78 vs 22%).ConclusionsFocal electrographic and electroclinical seizures with ipsilateral suppression of the background activity and focal sharp waves are strong indicators of PAIS. Approximately 80% of seizure events were the result of clinically unsuspected seizures in neonates with PAIS. Prolonged and continuous multichannel video-EEG monitoring is advocated for adequate seizure surveillance.
Highlights
80% of seizure events were the result of clinically unsuspected seizures in neonates with Perinatal arterial ischaemic stroke (PAIS)
[5] While cranial ultrasound scans have been shown to have good diagnostic capabilities when performed after day 4, [6] confirmation of diagnosis is only reliably achieved with magnetic resonance imaging (MRI); this facility is not readily available in many institutions
Accurate recognition of PAIS would be helpful in distinguishing neonates with seizures who do not fulfil the current criteria for therapeutic hypothermia, but who require thrombophilic screening and high quality MRI for diagnosis and prognosis
Summary
Perinatal arterial ischaemic stroke (PAIS) occurs approximately 1 in 2500 livebirths and is recognized as a common cause of early onset neonatal seizures. [1] Approximately 20% of neonatal seizures are due to PAIS, [2] and neonatal seizures have been noted in up to 26% of neonates with PAIS. [3] Generally, neonates with PAIS are non-encephalopathic but those with significant seizure burden can be neurologically abnormal, making the distinction from seizures due to other causes such as hypoxiaischaemia difficult in the acute neonatal period. [4] The diagnosis of PAIS should be suspected when seizures are observed in nonencephalopathic neonates within the first 48 hours of birth. [5] While cranial ultrasound scans have been shown to have good diagnostic capabilities when performed after day 4, [6] confirmation of diagnosis is only reliably achieved with magnetic resonance imaging (MRI); this facility is not readily available in many institutions.Electroencephalogram (EEG) or amplitude integrated-EEG (aEEG) is one of the first diagnostic tools available at the cotside in the neonatal intensive care unit for the assessment of cerebral function. Perinatal arterial ischaemic stroke (PAIS) occurs approximately 1 in 2500 livebirths and is recognized as a common cause of early onset neonatal seizures. [4] The diagnosis of PAIS should be suspected when seizures are observed in nonencephalopathic neonates within the first 48 hours of birth. EEG may distinguish neonates with PAIS from those with hypoxic-ischaemic encephalopathy (HIE) [3] and other aetiologies, providing invaluable support for clinical decision-making and counselling. Accurate recognition of PAIS would be helpful in distinguishing neonates with seizures who do not fulfil the current criteria for therapeutic hypothermia, but who require thrombophilic screening and high quality MRI for diagnosis and prognosis. The aim of our study was to characterize the early postnatal EEG findings in term neonates with PAIS who had seizures. Stroke is the second most common cause of seizures in term neonates and is associated with abnormal longterm neurodevelopmental outcome in some cases
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